Provider Newsbrief
October 2021
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Security Health Plan distributes Provider News digitally. Every other month, Provider Newsbrief focuses on policy changes, prior authorizations and other information for providers that is time-sensitive. If you wish to receive this monthly newsletter, please create a Provider Portal account by contacting your practice's organization administrator. If you don't have an organization administrator, click here to set one up.
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Medicare Advantage - Transition for COVID-19 vaccine
CMS has announced that Medicare Advantage plans will be responsible for COVID-19 vaccine services effective Jan. 1, 2022. Please plan to update your billing information to account for this change.
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National Public Health Emergency extended
Many Security Health Plan policies and coverages related to the COVID-19 pandemic are in effect until the end of the National Public Health Emergency. All indications are the public health emergency could run through at least the end of 2021. Read our updated COVID-19 Provider FAQ for more information. |
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Check back often to see how Security Health Plan processes help minimize COVID-19 impact on providers
Security Health Plan has developed processes for providers and a webpage to help answer questions about COVID-19 testing and treatment. Access our COVID-19 web page for timely updates. Also see the COVID-19 Provider FAQ for complete information on vaccines, new COVID-19 codes and other questions about testing and treatment.
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Security Health Plan earns 4.5 stars from CMS for Medicare Advantage HMO-POS plans
We have some exciting news for Security Health Plan and our provider partners! Earlier this month we learned Security Health Plan earned an overall rating for 2022 of 4.5 out of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for our Medicare Advantage HMO-POS plans. Read more
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Security Health Plan policy review - Effective October 2021
By KAREN BORGEMOEN, Nurse Navigator/Medical Policy Nurse
Security Health Plan reviews medical policies on a monthly basis. Medical policies are found in the provider section of the Plan's public website at www.securityhealth.org/providers. Read more for policy reviews and changes effective Oct. 1, 2021.
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Important online information is a click away
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Security Health Plan updates |
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Medicaid managed care programs require HIPPS codes for nursing home pricing
Effective for dates of service on or after Jan. 1, 2022, Security Health Plan will follow ForwardHealth guidance to pay nursing home claims using the Health Insurance Prospective Payment Systems (HIPPS) code to reimburse claims on an acuity-specific basis. Information can be found in the ForwardHealth Update 2021-22, “Nursing Home Acuity-Based Billing.”
Please ensure that your billing system is updated to submit the HIPPS codes in Form Locator 44 (HCPCS/Rare/HIPPS Code) of the UB-04 claim form. For non-developmentally disabled (DD) in-house residents, claims must be submitted with the revenue code 0022 and the appropriate HIPPS code for the patient’s acuity. For circumstances where a HIPPS code is unable to be determined, the default HIPPS code of ZZZZZ may be used but will be priced at the lowest possible reimbursement combination. Claims submitted without a HIPPS code or with an invalid HIPPS code will be denied.
There is no change to the billing requirements for claims submitted for non-DD bed-hold, DD in-house, or DD bed-hold.
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Several self-administered drugs moved to pharmacy benefit for 2022
By APRIL BORES, Manager - Claims Processing Government Programs
Dupixent, Fasenra, Firazyr and Nucala have been moved from the Home Infusion benefit to the Pharmacy benefit for the 2022 plan year as these drugs are generally self–administered. Members have been notified of the change.
In order to assist in the transition, please provide an updated prescription to the member’s Specialty Pharmacy, which will help avoid any delays in receiving their medication after the beginning of the new year. SHP Pharmacy Services will be available to assist with prior authorization paperwork that may be required to fill the specialty medication through the pharmacy benefit. If you have further questions, please contact Pharmacy Services at 1-877-873-5611 or via email at [email protected].
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Medicare Part B step therapy program update - Jan. 1, 2022
By KURT WITTIG, Clinical Pharmacy Specialist
The Centers for Medicare and Medicaid Services (CMS) previously issued guidance that provides Medicare Advantage plans the option of applying step therapy for physician-administered Part B drugs in a way that lowers costs and improves the quality of care for Medicare beneficiaries.
Security Health Plan first implemented step therapy requirements on May 1, 2019, and has added to the program periodically for NEW starts of certain targeted drugs.
Read more for drugs added to the program for dates of service on or after Jan. 1, 2022.
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FDA grants accelerated approval for Alzheimer's drug;
Security Health Plan excludes from coverage at this time
By ANDREA SEDLACEK, Clinical Pharmacy Specialist
The U.S. Food and Drug Administration (FDA) recently approved aducanumab (Aduhelm™) as the first drug to treat Alzheimer’s disease. It was approved via the FDA’s accelerated approval process based on the surrogate endpoint of reduction in amyloid beta plaques. Controversy remains over whether or not reduction of amyloid beta plaques in the brain is associated with improved clinical outcomes, resulting in some major medical institutions not providing and some doctors not comfortable prescribing it. CMS is currently undertaking a National Coverage Determination analysis (due in 2022) to carefully review and determine whether Medicare will establish a national Medicare coverage policy for monoclonal antibodies targeting amyloid for the treatment of Alzheimer’s disease.
Based on current information, the Security Health Plan Pharmacy & Therapeutics Committee voted to exclude aducanumab (Aduhelm™) from coverage, as it is considered an experimental and investigational medication at this time.
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Prior authorization updates |
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January 2022 updates to prior authorizations and post service claim edits
By AMANDA SIEGLER, Clinical Pharmacy Specialist
Security Health Plan requires prior authorization (PA) and post service claim edits (PSCE) on medications in order to ensure coverage and payment for those services. A number of requirements have been added for 2022 as we work to make sure all care, services and treatments are medically necessary. Read more
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First Tier, Downstream and Related Entities (FDR) compliance requirements
Security Health Plan is responsible for fulfilling the terms and conditions of our contracts with the Wisconsin Department of Health Services and/or the Centers for Medicare and Medicaid Services and meeting applicable compliance program requirements. Security Health Plan requires each practice, as our first tier delegated business partner, to complete an annual Delegated Business Partner Attestation to ensure you are also in compliance with the same compliance program requirements, applicable laws, rules and regulations as our downstream entity.
Read more for details about the FDR Attestation and Security's tools to assist you in meeting your regulatory requirements.
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